Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) can be performed either by a transperitoneal (TP) or a retroperitoneal (RP) approach. However, the superiority of one approach over the other is not established. Hence, the primary aim of this review was to compare perioperative outcomes between these two surgical approaches. METHODS: Literature was systematically searched to identify studies reporting perioperative outcomes following TP RAPN and RP RAPN. The study protocol was registered with PROSPERO (CRD42023399496). The primary outcome was comparing complication rates between the two approaches. RESULTS: This review included 22 studies, 5675 patients, 2524 in the RP group, and 3151 in the TP group. The overall complications were significantly lower in the RP group [Odds ratio (OR) 0.80 (0.67, 0.95), p = 0.01]. However, the rate of major complications was similar between the two groups. The operative time was significantly shorter with the RP group [Mean Difference (MD)-16.7 (- 22.3, - 11.0), p = < 0.0001]. Estimated blood loss (EBL) and need for blood transfusion (BT) were significantly lower in the RP group. There was no difference between the two groups for conversion to radical nephrectomy [OR 0.66 (0.33, 1.33), p = 0.25] or open surgery [OR 0.68 (0.24, 1.92, p = 0.47] and positive surgical margins [OR 0.93 (0.66, 1.31, p = 0.69]. Length of stay (LOS) was shorter in the RP group [MD - 0.27 (- 0.45, - 0.08), p = < 0.00001]. CONCLUSIONS: RP approach, compared to TP, has significantly lower complication rates, EBL, need for BT and LOS. However, due to the lack of randomized studies on the topic, further data is required.

Human epidermal growth factor receptor 2/neu expression in urothelial carcinomas.

Introduction: Urothelial carcinomas of the bladder are more common in males, making them the sixth-most common cancer in men and the tenth-most common cancer overall, worldwide. Current guidelines do not recommend routine testing for human epidermal growth factor receptor (HER2/neu) expression on the biopsy specimens of patients with urothelial carcinoma. This study was aimed at determining the expression pattern of HER2/neu and its usefulness in muscle-invasive and nonmuscle-invasive urothelial carcinoma. Methods: HER2/neu expression was assessed in 89 specimens of urothelial cancer by immunohistochemistry (IHC), and equivocal cases were subjected to fluorescent in situ hybridization (FISH). Results: On IHC for HER2/neu, 17.9% (7/39) of the muscle-invasive bladder cancers (MIBCs) showed a 3+ expression, whereas 22% (11/50) of the non-muscle invasive cancers were positive with a score of 3+. A significant correlation between HER2/neu status and muscle invasion could not be established in the current study (P = 0.74, Fisher's exact test). Three cases of muscle-invasive (7.7%) and 2 cases (4%) among nonmuscle invasive cancers showed equivocal expression. All the cases with equivocal (2+) expression on IHC were subjected to FISH and none showed gene amplification on hybridization and were considered as negative. Conclusion: Overexpression of HER-2/neu was seen in 17.9% of MIBCs and 22% of non-MIBCs. There are no norms for routine testing of HER2/neu expression in the biopsy specimens of urothelial carcinoma. There is an unmet need to establish guidelines for HER2/neu scoring, similar to that for breast and gastric cancers, to determine the proportion of positive cases and help in identification of those who may benefit from targeted therapies.

Extranodal Rosai-Dorfman disease: A rare mimicker of metastatic renal cell carcinoma.

A 29-year-old female presented with the history of pain in the abdomen and a palpable lump in the right hypochondrium, lumbar, and the umbilical regions for the past 2 months. On evaluation with contrast-enhanced computed tomography (CECT) and positron emission tomography CT, she was found to have a heterogeneously enhancing mass entirely replacing the mid and the lower pole of the right kidney, the pelvis, and the upper ureter with loss of fat planes with the inferior vena cava, psoas muscle, and the hepatic flexure, along with pericardial deposits and soft tissue lesions at multiple paravertebral regions and the right thigh. Owing to a high suspicion of metastatic renal cell carcinoma (RCC), a right cytoreductive nephrectomy was performed. Histopathology revealed extranodal Rosai-Dorfman disease, which was mimicking a metastatic RCC on imaging. The patient was started on oral steroids to control the distant lesions and to prevent progression of the disease and is doing well at follow up.

Renal mucormycosis presenting during the COVID-19 pandemic: A series of 11 cases from a tertiary care center in India.

Introduction: Renal mucormycosis has been documented to occur even in apparently immunocompetent individuals. Owing to the rarity of this disease, literature on its management is small. We present our experience of diagnosing and managing 11 cases of primary renal mucormycosis who presented during the second wave of the COVID-19 pandemic in India. Methods: We reviewed the records of all patients presenting to our institute with a diagnosis of acute pyelonephritis from March 2021 to September 2021. All patients with a radiological, microbiological, or histopathological diagnosis of renal mucormycosis were included in the analysis and all demographic and clinical details, including a history of COVID-19 disease and its treatment, were noted. All patients were treated by a combination of intravenous antifungal therapy and aggressive surgical debridement including nephrectomy and multivisceral resection as required. Predictors of mortality were evaluated by statistical analysis. Results: A total of 93 patients presented to our hospital with features of acute pyelonephritis of which 11 patients were suspected to have primary renal mucormycosis based on characteristic imaging features and confirmed on microbiological and histopathological examination. Of these, four patients had a history of COVID-19 infection. Only one patient had diabetes mellitus. Ten patients underwent nephrectomy and seven needed resections of surrounding organs. The colon was the most commonly involved organ. Five patients (45.5%) died of progressive sepsis. None of the predictors of mortality that were analyzed showed statistical significance. Conclusion: A high index of suspicion, early cross-sectional imaging, prompt institution of antifungal therapy, and aggressive surgical extirpation are very important for achieving good outcomes in patients of primary renal mucormycosis.

COVID-19 and fatal renal mucormycosis: Contributory or coincidental?

Association of mucormycosis with COVID-19 disease is emerging as a matter of concern, with multiple reports of rhino-cerebral-orbital and pulmonary involvement. The association of isolated renal mucormycosis in a patient with a history of COVID-19 infection is unknown. The immune dysregulation associated with COVID, along with the use of steroids, mechanical ventilation, and interleukin-6-directed therapies, predisposes to the development of mucormycosis. We report a rare case of primary renal mucormycosis in a young male following recovery from COVID-19. The unusual mode of presentation, rapidly progressive disease course, and the ensuing dilemmas in diagnosis and treatment merit critical analysis.

Giant-cell tumor of the urethra: Report of an unusual case.

Urethral strictures may present due to many causes. Obstructive urinary symptoms secondary to urethral malignancy is a rare presentation. Moreover, primary giant-cell tumor (GCT) arising in the urethra is an extremely unusual entity, which, to the best of our knowledge, has not been described till date; therefore, the clinical behavior is uncertain. We report a clinically unsuspected case of GCT of the urethra, who presented with urethral stricture.

Case Report: Scorpion Envenomation with Delayed Ischemic Priapism in a Preadolescent-An Unusual Presentation.

Priapism as a complication of scorpionism in children is rare and is categorized as grade II of severity. The pathogenesis is the activation of parasympathetic pathways that stimulate the release of acetylcholine. An 8-year-old boy, a known case of steroid-dependent nephrotic syndrome, presented with a history of persistent penile erection for the previous 12 hours. He had a history of a black scorpion (Heterometrus swammerdami) sting on his right leg 4 days earlier. He was given adequate analgesia, and prazosin was started at 30 µg/kg/dose because of the parasympathetic overactivity. Doppler ultrasonography of the penile shaft showed a bilateral thickened, bulky, and edematous corpus cavernosa and no arterial flow due to venous congestion, suggesting ischemic (low-flow) priapism. Detumescence was not accomplished with saline irrigation and aspiration or with intracorporeal irrigation with phenylephrine. Thus, a distal T-shunt was done. We illustrate an interesting case of scorpion envenomation with delayed ischemic priapism.

Analysis of the urethral stricture score and patient-related factors as predictors of outcomes following oral mucosal graft urethroplasty.

Objective: The complexity of urethral strictures can predict outcomes following urethroplasty. The previously described urethral stricture score (U score) considered only stricture-related factors to grade the complexity of urethral strictures and to predict recurrence post urethroplasty, but not considered patient-related factors for the same. We aimed to study the correlation of both of these factors to the outcomes of oral mucosal graft urethroplasty. Methods: We retrospectively reviewed data of 101 patients who underwent oral mucosal graft urethroplasty in our institute with a minimum follow-up of 6 months. Baseline patient characteristics and stricture-related parameters were noted. The U score was calculated for all patients which consisted of the length, location, number, and etiology of stricture. Univariate and multivariate Cox proportional hazard regression models were used to determine significant risk factors of recurrence. Results: The mean follow-up of patients was 15 months. Recurrence was seen in 28 patients and the mean time for detection of recurrence was 8 months of follow-up. The Charlson Comorbidity Index, history of previous intervention, length of strictures, location of strictures, number of strictures, history of smoking, and etiology were independent predictors of recurrence following urethroplasty. Based on these parameters, we formulated the modified U score (MU score). The scores ranged from 0 to 6 and a score of >2 was found to be predictive of recurrence. On comparing receiver operating characteristic curves for both scores by the DeLong test, the MU score had larger area under the curve than the U score. Conclusion: The MU scoring system is the first of its kind attempt taking into consideration both patient- and stricture-related factors to predict recurrence following oral mucosal graft urethroplasty.

Assessing pentafecta outcomes post radical cystectomy: A tertiary care center study.

INTRODUCTION: Bladder cancer is a common and serious disease globally, often requiring radical cystectomy as the preferred treatment. However, this procedure carries substantial risks and complications. To evaluate its success, pentafecta, a five-component measure, was introduced. This study investigates the attainment of pentafecta following radical cystectomy and examines factors that influence its achievement. METHODOLOGY: This retrospective, single-group study was conducted at AIIMS Jodhpur. The study population included 42 patients who underwent radical cystectomy for bladder cancer. Various data, including demographic characteristics, clinical features, surgical techniques, and postoperative outcomes, were collected from medical records. The primary outcome measure was the rate of achieving pentafecta, which comprises five parameters. RESULTS: Out of 42 patients, 26 (61.9%) achieved pentafecta. Age, gender, comorbidities and surgical approach did not significantly affect the attainment of pentafecta. Negative surgical margins were achieved in 95.2% of cases, and adequate lymph node dissection (>16 lymph nodes) was performed in 85.7% of cases. The absence of Clavien-Dindo grade 3-5 complications and recurrence was observed in 80.9% and 90.47% of cases, respectively. Uretero-enteric stricture was absent in 95.2% of cases. CONCLUSION: The study emphasizes the significance of negative surgical margins, thorough lymph node dissection, absence of complications, recurrence, and uretero-enteric strictures in evaluating the success of radical cystectomy as pentafacta outcomes. Patients with higher drain output and wound infections are less likely to achieve pentafacta outcome and indicates poorer outcome. By considering these factors, clinicians can assess patient outcomes and identify areas for improvement.

Correlation of urinary continence recovery with various factors after Robot assisted radical prostatectomy.

BACKGROUND: In addition to ensuring cancer control, prevention of incontinence which significantly impact patients' quality of life, is also an important issue in robot-assisted radical prostatectomy (RARP) operations. In this study, we aimed to find the correlation of urinary continence recovery with various factors after Robot assisted radical prostatectomy. METHODS: This study included 162 patients treated with RARP with perioperative data and at least 1 year of follow-up. Also, the preoperative, intraoperative, and postoperative parameters of the patients were analyzed. The continence recovery rate in our study was assessed at 6th week, 3rd month, 6th month, 9th month, and 12th month, post-surgery. Logistic regression analysis evaluated the association between the predictive factors and urinary continence recovery in the early and late stages. RESULTS: The majority of patients with prostate cancer present in sixth decade of life. The majority of our patients (56.7%) were categorized as high risk using D'Amico classification. The continence rate in our study at 6th week, 3rd month, 6th month, 9th month, and 12th month were 40.1%, 72.2%, 85.2%, 89.5%, and 91.4%, respectively. No improvement in continence status was observed after 1 year in our study. There was significant correlation of age with continence status at 6th week, 3rd month, and 6th month. The young age is associated with early recovery of continence. At 3 and 9 months, the non-diabetics cases achieved significantly higher continence rates than diabetics (p < 0.05) which shows that diabetes causes delay in attainment of continence. CONCLUSION: The young age may be associated with early recovery of continence, but further validation requires large number of cases. We attributed good continence recovery rate to meticulous dissection and preservation of good urethral length.

Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature.

OBJECTIVES: Lymphatic channels (LC) are not as prominent as blood vessels, so they tend to get damaged during surgical procedures. It can present with chyle leak in the postoperative period. We aimed to study the occurrence of chyle leak in patients undergoing nephrectomy and its management. METHODS: During the period of January 2021 and January 2023, 158 adult patients underwent nephrectomy for various reasons like non-functioning kidney, donor nephrectomy, and malignancy. We retrospectively analyzed data of patients who had chyle leak after nephrectomies. RESULTS: Eight patients out of the 158 patients (5.06%) undergoing nephrectomy developed chyle leak. One out of these eight patients underwent nephrectomy by open approach while seven underwent laparoscopic approach. All eight patients who had chyle leak undergone left sided nephrectomy. Six patients of chyle leak could be managed with dietary modification while two patients needed octreotide therapy for treatment. Higher Body Mass Index (BMI; p-value = 0.012), left sides nephrectomy (p-value = 0.013), h/o pyelonephritis (p-value = 0.005) were associated with higher incidence of chyle leak on univariate analysis. While on multivariate analysis no factor was found to be independently associated with chyle leak. Hospital stay was significantly prolonged in patients with chyle leak (p-value = 0.007). CONCLUSION: Chyle leak is not a very rare complication after nephrectomy. Patients with higher BMI, who undergo left sided nephrectomies and patients who had history of pyelonephritis or infectious complications had higher incidence of chyle leak. Most cases can be managed with conservative management (CM). Chyle leak is associated with a prolonged hospital stay.

Early port site and peritoneal metastasis following robot-assisted radical cystectomy: a rare case report.

Radical cystectomy with pelvic lymph node dissection is the recommended treatment for managing muscle-invasive carcinoma of the urinary bladder. Early recurrence is observed in only about 4.1% of cases. Port-site metastasis following robot-assisted radical cystectomy is extremely rare. We encountered a challenging and a rare case of bladder cancer that manifested with port-site and peritoneal metastasis within 6 weeks of surgery.

Discrepancies in Gleason score between needle core biopsy and radical prostatectomy specimens with correlation between clinical and pathological staging.

BACKGROUND: The studies have shown that GS given after assessment of the entire prostate gland on the radical prostatectomy specimen may differ from GS given after examination of a small sample from needle core biopsy. We conducted this study to assess discrepancies in the Gleason score between NCB and RP specimens and to find out the correlation between the clinical stage and pathological stage. METHODS: The study included 174 patients with carcinoma prostate which underwent robotic-assisted radical prostatectomy (RARP). Pre-operative Gleason score was determined on 12-core biopsy samples under trans-rectal ultrasound (TRUS) guidance. The Gleason score obtained from the radical prostatectomy specimen was compared with that of the NCB Gleason score to find out differences. RESULTS: The preoperative Gleason score (GS) ranges from 6 to 9 with a mean GS of 6.97 ± 1.02. The post-operative GS ranges between 6 and 10 with mean and GS of 7.5 ± 1.10. On the pre-operative assessment of biopsy specimens, 70 (43.2%) patients had a GS of 6, while 44 patients had a GS of 7 (27.1%) and 48 (29.8%) patients had a GS of more than 7. On the postoperative assessment of specimens, 31 (19.1%) patients had post-operative GS of 6, while 66 (41%) patients had GS of 7 and 74 (41.1%) patients had GS of more than 7. When pre-operative GS and post-operative GS were compared, no changes were observed in the GS of 79 patients, whereas 83 patients showed the difference in GS, with 75 patients showing up-gradation and eight patients marked as down-graded. CONCLUSION: concordance between biopsy and the pathology results directly affects the prognosis of the patient. The results of our study demonstrated the rate of discordance between Gleason scores obtained from transrectal prostate biopsy and RP surgical specimens. This rate brings into question the accuracy of the chosen treatment.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique.

INTRODUCTION: We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies. MATERIALS AND METHODS: This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement. RESULTS: A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months. CONCLUSION: Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Endourological management of ureteric stump syndrome.

A man in his 50s presented with right flank pain and intermittent haematuria for 15 days. He was evaluated and diagnosed to have bilateral staghorn renal calculi with left poorly functioning kidney. He underwent right kidney stone clearance followed by laparoscopic left simple nephrectomy. Postoperatively, he developed recurrent urinary tract infections. On evaluation, non-contrast CT of the abdomen revealed calculus in left ureteral stump and he was diagnosed to have ureteric stump syndrome. He underwent ureteroscopy which revealed multiple stump calculi and complete stone clearance was achieved. Currently, the patient is asymptomatic and doing well after a follow-up of 1 year.

Postradical cystectomy delayed urethral recurrence: a rare presentation posing diagnostic dilemma.

The incidence of urethral recurrence after radical cystectomy is 1% to 8%, with most cases occurring within the first 2 years of surgery. Prophylactic urethrectomy is rarely performed nowadays due to no known survival benefit and increased morbidity due to the procedure. However, we encountered a rare case of delayed urethral recurrence presenting as recurrent urethral collection 4 years after radical cystectomy with ileal conduit diversion, posing a diagnostic dilemma.

Retained foreign body post-PCNL: an unusual complication and endoscopic management.

During this era of advanced and minimally invasive procedures for treating urolithiasis, percutaneous nephrolithotomy (PCNL) remains the primary choice for removing large renal calculi. While there are various known complications associated with PCNL, such as bleeding, sepsis and injury to neighboring organs, the occurrence of retained foreign bodies as a result of the procedure is rarely reported. In this case report, we present a unique instance of encrustation involving a retained guidewire sheath following PCNL, which was initially mistaken for a residual stone fragment in imaging studies. Fortunately, the foreign body was successfully removed using retrograde intrarenal surgery.